I have a dream - A change of generations - Communication channels - Book vs. internet - Pioneer
projects - Traditional publishing house or the author as publisher? - Cash flow - The world needs
100 doctors

Just imagine:

A medical textbook is available on the internet, accessible for everyone at
all times.

Even better: it is already on the internet although sales of the print
version have not even begun yet.

Furthermore: the book is updated every year.

And hard to believe: access on the internet is unrestricted, 800 pages just
waiting for readers.

Utopia?

Reality! It has been possible to read free of charge on

www.HIVMedicine.com for a number of years now.
In future, the textbook will be updated annually and made available on the internet. HIV Medicine:
written by doctors, edited by doctors, published by doctors - for doctors. You are among your own
kind. The advantage: unparalleled dedication from the authors and extremely short production times,
which means that there is hardly any other book project in existence where up-to-date medical
information is processed as quickly as in HIV Medicine. This has far-reaching consequences. The
continuously updated specialised knowledge which is published in the duo of book + internet becomes
a kind of permanent advanced training course, free of charge, prompt and ubiquitous. All thanks to
the internet.

HIV Medicine 2005 is a so-called Flying Publisher text. Flying Publisher
texts exist 1) in book form and 2) simultaneously as a free internet site. So a Flying
Publisher text has two physical conditions, a fee-based form (book) and a free-of-charge form
(internet). Flying Publisher texts speed up the flow of information.

Just imagine,

if there were not only textbooks on HIV and AIDS, but also on other subjects,
such as immunology, rheumatology, cardiology, antibiotic therapy, tropical medicine. Or - why ever
not? - even for every possible medical field, as well as for the most important sub-sections (see
the overview given on

www.amedeo.com). In
an instant, we would have an extensive virtual library with all the relevant information needed for
day-to-day use. 100 books, 50,000 pages, free of charge, updated yearly. 99% of the questions which
crop up in our daily medical routine would be covered.

Sceptics express concern that doctors already have enough work
to do and thus can't cope with being writers and publishers of free internet textbooks at the same
time.

First of all, they underestimate us. Secondly, the sceptics - especially if they
are not doctors themselves - are not quite in step with the times. In the last five years, the
internet has drastically reduced costs and time involved in the production and marketing of
information of every kind. Nowadays, doctors can pass on their knowledge directly to colleagues and
students, whether by e-mail, PDF files or through their own websites. Doctors no longer have to work
together with publishing companies.

It is time, once more, for a generation change. Until recently, those who
published textbooks - mostly 45 and older - were too old to understand the internet. Those, on the
other hand, who had some idea of the possibilities offered by the internet were too young and
inexperienced, and therefore not ready to write textbooks yet. But, as time passes, people get older
and the old ones, too old for the internet, take their leave and the young ones, young enough for
the internet, get older and reach the age at which they can write textbooks.

In the following chapters, we will work our way step by step through the process
of how an idea becomes a text and how we get this text to our readers. The individual stages of this
adventure are:

Selecting and narrowing down a theme, structuring the material and putting
together a team of authors

Writing the text and guiding the authors

Preparations behind the scenes, while the authors are writing

Talks with sponsors

Refining and polishing work on the chapters until we have a version ready for
press

Advance publication of the texts on the internet Advertising and marketing

Advertising and marketing

Copyright clearance for translation into other languages

Before describing these points in detail, we have to go back to basics. What is
communication? What do I want to achieve by writing this text? How many readers am I writing for?
What is the difference between books and internet sites? What is more important: money or readers?
Does it make more sense nowadays to publish a text in a traditional publishing house or as my own
publisher? What is the cash flow like in a book project and what cash flows where?

Communication is the transportation of thoughts, ideas, wishes,
images or visions from one brain to another. When you stand up in front of a group of students in a
lecture theatre, some things are only in your head, but not in the heads of the students. You speak
for an hour and remedy this situation.

If we want a message to reach more people, we need media other than language. In
the course of history, people have invented cuneiform writing tablets, papyrus, manuscript, books,
radio, television and the internet. The first three media are no longer modern, and radio and
television are generally not available to us. This leaves us with books and the internet for the
communication of our knowledge.

The number of people we can reach with a message mainly depends on the subject.
The number of people interested can range from 6 thousand million (Message: "the 10-kilometre
meteorite is expected to hit three days before Christmas") to a few hundred (Message:
"total mesorectal excision and urogenital dysfunctions"). But regardless of how many
people are interested in a subject, the following rule applies: if I write and spend days and even
weeks formulating a text, I want as many people as possible from the group theoretically interested
in my text to read what I have written. I want the maximum conceivable audience for my text.

Books and the internet are the forms of communication media
available to us doctors (Table 1 and 2). The most important difference is that we pay for books, but
not for internet sites, and, in addition:

Readability: books are easier to read and more versatile in their
application

Number of readers: for 1000 book-readers there are 10,000 and more internet
readers

How up-to-date are they?: internet sites are more up-to-date than a
book

Table 1.1: Advantages of a book

Books

can be sold easily by publishers

are prestigious

are tangible

can be read easily in very different situations (beach, bath-tub etc.)

have authority

Table 1.2: Advantages of internet sites

Internet sites

cost the reader nothing

are more up-to-date than books

reach a lot of readers

speed up the flow of information

At first glance, books and the internet are very diverse media, at least when
pitted against each other. However, they give a different impression when put side by side and
combined (Table 1.3). A text which is produced as a combination of "book + internet"
leaves little to be desired.

Table 1.3: Book + Internet sites

Book + internet sites are

easy to sell + up-to-date

prestigious + have a lot of readers

suitable for the bath-tub + the computer

representative + around the world in an instant

In addition, books and the internet benefit from each other. A book on its own is
immobile - it takes internet sites to set the text in motion. Only then is it to be found standing
on every street corner of the internet, calling "Please take me with you!" In return, a
book is the best possible publicity for an internet site. It is only through books that internet
sites are archived correctly and given authority - among other things, because the authors have no
choice but to commit themselves in black and white. The result is that internet sites and books
complement each other, and nowadays a text is only represented adequately in the combination, book +
internet.

Anyone who doesn't understand the complementary
nature of book and internet sites should think very hard about whether writing still makes sense for
him. There is little doubt: out of two equally competent and detailed medical textbooks, the one
available free of charge on the internet will be the one to win favour with the readers. In a direct
confrontation between "book only" and "book + internet", "books only"
have a remote chance of survival. This fact means that the book with the free internet version
ultimately gains market shares. The surprising twist is that the free internet version promotes the
sale of the fee-based book version. The financial result of a well-planned parallel publication
(book + free internet counterpart) can thus be very satisfying in the middle-term. We will come back
to this point in more detail later.

The number of readers is one of the most important variables
which define the success of a text. We are investigating the extent to which this number is
influenced by the publication of a free internet version in three pioneer projects, and can already
anticipate the result. Texts on the internet have at least ten times as many readers as books
only.

The pioneer project for medical textbooks in the German-speaking part of the
world was HIV.NET. As early as Spring 1996, the 460 pages of "AIDS 1996" were available on
the internet. This practice has been continued until today (

* The internet access figures have been rounded off
** or rather: "potential readers", as not everyone who owns a book actually reads it and
not everyone who accesses an internet page reads it.

In 2004, about 1,000 books of the complete 712-page edition of HIV.NET were sold,
as well as 2000 copies of the abridged "pocket edition" with the central chapters HIV
Therapy, Drug Profiles, Side Effects, Lipodystrophy, Resistance Testing, Opportunistic Infections,
and Lymphomas.

The PDF version of the complete edition, which was freely available as of
14th July, was retrieved more than 5000 times in 6 months. Some chapters (Acute HIV
infection, HIV Testing) were read 10 times more often on a computer monitor than in a book.

www.HIVMedicine.com) roughly corresponds to the
pocket version of HIV.NET (see above). 3000 copies of HIV Medicine 2003 were printed and handed out
to the participants at an IAS congress in Paris by a pharmaceutical company.

* "Readers" should say "Potential readers" as not
everyone who owns a book actually reads it and not everyone who accesses an internet page reads it.
** 8th April to 16th November 2003; the figures correspond approximately to
the number of readers from 1st January to 31st December 2004.

By the end of the year 2004, the PDF version of HIV Medicine 2003
had been downloaded from our servers more than 24,000 times The chapters "Acute HIV
Infection" and "HIV Therapy" had an additional 25,000 and 13,000 readers,
respectively (see Table 1.5).

A novelty with HIV Medicine 2003 was the copyright removal (

http://hivmedicine.com/textbook/cr.htm, see details on page *). The simultaneous
message to colleagues all over the world was "Colleagues, translate HIV Medicine 2003 and
publicise the translation. If you want, you can even publish it under your own name. Sell the book,
earn money from it. Whatever you do: we don't want a cent."

3rd edition, PDF-File
16th October to 31st December 2003
1st January to 31st December 2004

6,000
12,000

SARS Reference Homepage

232,426

Chapter

Virology

42,214

Treatment

39,581

Timeline

36,482

Transmission

33,351

Summary

31,648

Other Languages

25,689

Epidemiology

22,855

Diagnostic Tests

22,574

Diagnosis

18,994

Case Definition

17,550

Paediatric SARS

10,826

Copyright Removal

9,572

* Access numbers, 8th May 2003 to 5th May 2005
** "Readers" should say "Potential readers" as not everyone who owns a book
actually reads it and not everyone who accesses an internet page reads it.

The PDF documents of the three editions were accessed more than 50,000 times; the
most important chapters were opened more than 30,000 times each.

As in the case of HIV Medicine 2003, we removed the copyright for SARS Reference.
The book was then translated into Chinese, French, Italian, Portuguese, Romanian, Spanish and
Vietnamese (see

http://sarsreference.com/sarsref/lang.htm). The two Chinese translations were also published as printed booklets and handed out to
7,000 and 10,000 Chinese doctors, respectively, at the peak of the SARS epidemic (see Fig. 1.1).

Figure 1.1: Cover of the second Chinese translation

SARS Reference had more than 200,000 readers in 20 months, because it was free of
charge. It was translated into 8 languages because it was free of charge and the copyright had been
removed. SARS Reference is in third place on the Google list after the CDC and the WHO, because it
is known throughout the world. SARS Reference was reviewed twice, in Science and in the British Medical Journal, because it showed new
ways of publishing medical information.

* Access numbers, 8th May 2003 to 5th May 2005
** "Readers" should say "Potential readers" as not everyone who owns a book
actually reads it and not everyone who accesses an internet page reads it.

The decision has been made: we are going to write a medical
textbook and publish it both as a book and on the internet. But how precisely do we set about
approaching this project? Do we have the publishing skills to achieve success? How do we organise
it? Can we cope financially?

Let's start by taking stock. In the last few years, doctors have seen how
amazingly self-sufficient they have become in spreading medical information. Whether we wanted to or
not, we have all become experts in word processing. Think back: how many doctors were familiar with
the layout of letters on a typewriter 20 years ago? Back then, we had secretaries, and anyone who
was able to touch-type kept this to himself and didn't give it away to his assistant until after he
retired.

Better still: we are not only adept at word processing but have also become
practised layout designers. Anyone who has published scientific articles in medical journals has
learned that he must "format" his texts in accordance with strict regulations. After all,
the work performed in the medical publishing houses must be reduced to a minimum.

And finally: today, we can transform a text into a PDF document within seconds
with just one mouse-click and then position it - once more, within seconds and with another
mouse-click - on a website.

What is left for medical publishing houses to do in this context? 20 years ago, a
text was sent to the publishers and

typed

proofread

typeset

printed

distributed

And today, in 2005? We type, our word-processing software typesets, PDF prints
and the Internet distributes the online version. Which brings us to the conclusion: if proofreading
is the only thing that stays in the hands of the publishers, why don't we just take over the whole
production process? The only problem left would be distribution, which - as we will see later on -
is a problem which can be solved for medical textbooks, 90% of which are sold in a relatively small
number of specialised bookstores. So, let us put the question more precisely: what do we do if we
have a finished manuscript? Do we go to a traditional publishing house or is it more beneficial to
produce the book in our own garage?

There is sometimes a sense of shame at the idea of publishing a written text
ourselves. "Self-published" or "author's own publishing house" gives off an aura
of cheap goods, discount stores and home-made socks from the post-war era. The argument: publishing
houses are seen as a supervisory body, and it is this supervision that awards our texts the seal of
approval, sanctifies our work, and renders sacred our Opus urbi et orbi.

This was not true in the past - and is even less so today. In the medical
publishing houses, more and more doctors are being replaced with economists. This may make sense
within the business, but are economists the right people for us to talk to?

Secondly, some medical publishing houses have suffered from globalisation,
philosophy of efficiency and lean production structures. In the past, bestsellers existed to bring
in enough money to help finance books which were not highly profitable but represented a meaningful
supplement to the range. The tendency today, not surprisingly, is to avoid having to keep any exotic
types on the payroll if at all possible, and to play safe and secure the financing of a new title
right from the start by selling part of an edition to a pharmaceutical company.

Thirdly, and this is perhaps the saddest point for doctors: morals are becoming
rougher, the rules of courtesy are sinking into oblivion. One generation ago, old people say,
courtesy and reserve ruled over any contact between doctors and publishers. This too is a thing of
the past. In the age of rapid production, the doctor is becoming a supplier of raw material, has to
meet delivery deadlines more than ever and is treated the way many people tend to treat delivery
men: rudely.

But to come back to the point mentioned at the beginning, that publishers are an
important supervisory factor for the quality of our texts. In principle, supervisory bodies make
sense, but are publishers the right ones for the job? Furthermore, which member of a medical
publishing house should have been allowed to decide at the beginning of May 2003 - when even the
specialists had only been aware of the extent of the SARS epidemic for six weeks - whether it was a
sensible move to publish SARS Reference or not? Who has the right to decide whether something
written by someone who has been practising his profession for 20 or 30 years should be
published?

Back to the question: "Publisher or garage?" Two reasons essentially
speak in favour of an author's contract with a traditional publishing house:

The short-term image boost is stronger if your book is published by an
established publishing house.

You don't need to bother with the marketing of the book.

The arguments that go against an author having a contract with a traditional
publisher are:

as a rule, you have to cede the rights to your own text;

it is seldom possible today to persuade publishers to present a free parallel
publication of the text on the internet;

producing your own book can be considerably more lucrative.

Thus, the following speak in favour of publishing your medical textbook by
yourself:

The better long-term remuneration.

The better establishment of your textbook in the long-term, since the
parallel publication of a text both as a book and an internet version is still rare today. This
gives you a selective advantage over authors who continue to publish their texts as books
only.

And of course, most important of all: you keep hold of the power. You never
know what the future may bring. Just imagine if I had ceded the rights to AIDS 1991 to a publishing
house in 1990. 5 years later, the internet comes up with possibilities we had no way of
anticipating. But the rights are gone, my hands are tied. There would have been no HIV.NET, no
Amedeo, no Flying Publisher - all because of one bad decision.

We therefore advise all colleagues to produce and market their textbooks
themselves.

The final price of a book, i.e. the price paid by the purchaser
in a bookshop, is essentially made up of the items printed, distribution and profit.

Print: the share that print costs have in the retail price depends on the
size of circulation and the price. At a fair price (e.g. HIV Medicine 2005: 50 Euro for 800 pages),
at a circulation of 500 copies, the printing costs amount to 14 Euro per copy, or 28% of the retail
price, for 1000 copies 10 Euro, or 20%, and for 2000 copies 6.75 Euro, or 13.5%.

Distribution: the share of distribution costs amounts to approximately 45% of
the retail price. This percentage is irrespective of the distribution channels (book wholesaler,
sponsors).

27 to 40% are considerably higher than the authors' royalties, which are
generally between 6 and 10% of the retail price.

Figure 1.2 illustrates how cash flows when the authors (A) have ceded their
rights to a traditional publisher. The future reader (R) goes into a bookshop (B) and pays the
retail price (yellow arrow). The bookseller or wholesaler pays the publishing house (X) after
deducting a sales margin of 30 to 45%. The publisher has previously transferred payment for the
printing costs to the print shop (P) and pays the authors off over several months or years.

Figure 1.2: Book production is outsourced to a traditional publishing house. Example for an
impression of 1000 books. The thickness of the yellow arrows reflects the volume of money which
flows.

The circumstances in Figure 1.3 are simpler, and more beneficial for the
author.

The publishers are out of the game and the authors market the books directly
through the most important specialised medical bookshops. The future reader (R) goes into the
bookstore (B), pays the retail price, and the bookseller remits 70% of this to the authors (A). The
authors have previously transferred payment of the printing costs to the print shop (P).

Figure 1.3: Book production with the author as publisher. Example for a circulation of 1000
books. The thickness of the yellow arrows reflects the volume of money which flows.

The circumstances in Figure 1.4 are even simpler than this. In this diagram, we
have replaced the bookstore with a sponsor, such as a foundation (S). The sponsor pays the authors
for the discounted books, and the authors in turn pay the printer (P). The reader (R) generally
receives the books free of charge and is grateful (blue arrow).

Figure 1.4: Book production with the author as publisher. One or more sponsors have taken on a
circulation of 1000 books and give the books away to doctors who are interested. The thickness of
the yellow arrows reflects the volume of money which flows. Blue arrow: gratitude

In chapters 2 and 4 we go on to develop the thoroughly fascinating subject of
financing and we will see that it is by no means ruinous to manufacture and market books. We also
investigate the sales figures needed to make book production financially interesting. You already
know that profits from book production can be two to six times higher than an author's
royalties.

We would like the most important medical fields to be covered in
freely available textbooks on the internet by the year 2010.

Medicine is not an unlimited area. The most important subjects can be covered in
100 textbooks. 100 doctors are wanted. 100 doctors can make the decision that up-to-date medical
information will be available free of charge. 100 doctors who, because they have their ears to the
ground, can use their project to push aside all comparable texts which exist in book form only. We
need 100 clever, dedicated and far-sighted doctors. 100 doctors to revolutionise access to
information.

Whoever starts running now might be first past the post, and whoever gets
established first will have a head start which will make it hard for competitors to catch up. And
that is only the beginning. If you keep your copyright, you are your own master and can enjoy
previously undreamed of liberties. This freedom makes things possible which would have been
considered utopian just a few years ago. Copyright removal is one of the magic words you have come
across in connection with

What have you learned from this chapter? And what should you
still remember tomorrow? That depends on whether you are an editor, an author, a doctor, a student
or an interested bystander.

Editor/Publisher

Today, a text should be published simultaneously in a
book and on free internet sites. If you write for a book only, you reach considerably fewer readers
than someone who publishes both in a book and on the internet at the same time.

Of two equally competent and detailed medical textbooks, the one that will
win the favour of the reader is the one that appears free of charge on the internet. In a direct
comparison of book only and book + internet, "books only" have little chance of
survival.

The financial result of a well-planned parallel publication can be much more
generous that it would seem at first glance.

Author

If an editor asks you to write a chapter for a
medical textbook, ask him if the text will be accessible free of charge on the internet. If not,
find out if there are any better projects to be had. Your work - and the chapters you write - do not
deserve to be locked up in a book only.

Doctor

If you have the choice between two equally good and
comparably substantial books, buy the book which is available free of charge on the
internet.

Student

Ask your professors if they have ever worked on a
Flying Publisher textbook.

Bystander

Would you have believed that doctors have the
knowledge and skills needed to produce their own textbooks? And can earn two to six times as much
money doing it than through the usual author's royalties?